Exploring the importance of inclusion criteria beyond the color of skin: Improvement in facial redness in skin of color subjects—An open-label, single center clinical study utilizing low molecular weight heparan sulfate
Authors: Eva Simmons-O’Brien, Valerie D. Callender, Diane Orlinsky, Shahzeb Hassan, Chidubem A.V. Okeke, Angel S. Byrd
Journal: Journal of the American Academy of Dermatology (2023)

To the Editor: The awareness of skin of color (SOC) in dermatology is expanding; however, a lack of diversity in dermatologic clinical trials persists,1Elston D.M. Letter from the editor: diversity and inclusion in clinical trials link to JAAD-D-21-03191.J Am Acad Dermatol. 2022; 87: 981-982https://doi.org/10.1016/j.jaad.2022.05.041Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar especially considering the inclusion of African Americans/Blacks.2Okeke C.A.V. Bhayana M. Simmonds F.C. et al.Improving African American enrollment in hidradenitis suppurativa clinical trials: a clinical and research staff perspective.J Am Acad Dermatol. 2021; 85: AB47https://doi.org/10.1016/J.JAAD.2021.06.215Abstract Full Text Full Text PDF Google Scholar,3Ferguson J.E. Vetos D. Ho B.V. et al.Trends in diversity of participants in dermatology clinical trials over time: a systematic review.J Am Acad Dermatol. 2022; 86: 1403-1405https://doi.org/10.1016/J.JAAD.2021.05.052Abstract Full Text Full Text PDF Scopus (0) Google Scholar This study provides evidence of how SOC can be excluded and/or underestimated for severity of symptoms because redness can be overlooked by visual examination. This open-label, single center clinical study assessing SOC using clinical grading and biophysical testing reveals the positive results and benefits of a daily regimen containing a patented low molecular weight heparan sulfate—heparan sulfate analog (HSA). This work highlights how SOC subjects, especially those with darker skin tones, may be omitted from study analyses due to visual clinical grading limitations. Twelve subjects, Fitzpatrick skin types III to VI (African American/Black [75%], American Indian or Alaska Native [16.7%], and Asian [8.3%]), were included in the intent-to-treat population. Subjects used HSA and cleanser twice per day (AM/PM) and sunscreen SPF 52 tinted or SPF 49 untinted at least once per day (AM). Clinical evaluations were conducted at visit 1 (baseline), visit 2 (week 2), and visit 3 (week 4). Subjects participated in the following procedures at each time point: clinical grading of efficacy parameters,4Griffiths C.E. Wang T.S. Hamilton T.A. Voorhees J.J. Ellis C.N. A photonumeric scale for the assessment of cutaneous photodamage.Arch Dermatol. 1992; 128: 347-351https://doi.org/10.1001/archderm.1992.01680130061006Crossref PubMed Scopus (199) Google Scholar tolerability evaluations, Mexameter measurements, VISIA-CR imaging, and self-assessment questionnaires. Another component of the study was to collect skin swabs, at baseline and week 4, to analyze the inflammatory markers IL-1α, IL-1RA, and PGE2. Notably, none of the SOC subjects qualified for the swab study because of the criteria of having visible moderate to severe facial redness. Although there was a decrease in local cutaneous global erythema at 4 weeks compared to baseline evaluated by signs and symptoms of clinically graded facial redness (Supplementary Fig 1, available via Mendeley at https://doi.org/10.17632/6bw7rjn2db.1, upper panel), this was not as apparent as the decrease in facial redness captured by bioinstrumentation measurements (Supplementary Fig 1, available via Mendeley at https://doi.org/10.17632/6bw7rjn2db.1, middle panel). The HSA regimen resulted in true reduction in redness as assessed by the Mexameter measurements (2.2% decrease in melanin, 5.6% decrease in hemoglobin) (Supplementary Fig 1, available via Mendeley at https://doi.org/10.17632/6bw7rjn2db.1, middle panel) indicating an improvement in erythema/facial redness at 4 weeks compared to baseline that was not captured to the same extent by visible clinical grading. This resulted in exclusion of these individuals from the inflammatory marker assessment due to the lack of apparent moderate to severe facial erythema by visible clinical grading. The self-assessment questionnaire and tolerability evaluations (Supplementary Fig 1, available via Mendeley at https://doi.org/10.17632/6bw7rjn2db.1, lower panel) revealed the regimen did not cause cutaneous irritation and was highly favorable among subjects. The HSA regimen tested substantially improved redness in SOC (Fig 1 and Supplementary Fig 2, available via Mendeley at https://doi.org/10.17632/tjxzcpjycp.1). However, due to visible grading inclusion criteria, these subjects were excluded from any analysis to correlate the reduction in redness to reduced inflammation. This highlights the critical need for careful consideration and evaluation of the various cutaneous presentations in SOC to ensure that underlying redness and potential inflammation are not overlooked in this population. The use of biophysical testing and visible grading promotes the inclusion and retention of SOC in clinical studies. Such actions will prevent explicit and unconscious biases, ensuring medical grade skin care products are generalizable to all. ASB is a consultant for Senté, Inc. ES-O, VDC, and DO have participated in Advisory Boards for Senté, Inc. SH and CAVO have no conflicts of interest to declare. We kindly thank all study participants. Also, we would like to thank Tanya Rhodes, PhD for her critical review of the manuscript and feedback. The clinical study (SGS Stephens Study Number: C21-P009) was conducted by SGS Stephens, Inc, Phoenix Research Center (2421 West Peoria Ave, Suite 124 Phoenix, AZ 85029).